Acute Care Authorization Analyst

Job Description

Job Description

Job Summary

This analyst works within the UM/UR and Crisis Departments. This person is responsible for providing clinical oversight, advocacy, and authorization for individuals being assessed for higher levels of care. The Analyst will complete retrospective reviews, specialist reviews and is also responsible for promoting appropriate, effective, and efficient use of resources via initial authorizations and concurrent reviews of acute care authorizations.

Essential Functions

• Assess verification of insurance, county of financial responsibility (COFR), and ensure that acute care criteria guidelines have been met.
• Provide timely and comprehensive analysis of acute care initial authorizations according to established clinical protocols and diagnostic criteria.
• Assist individuals in accessing necessary crisis services as medically appropriate and in the least restrictive environment.
• Leverages clinical knowledge, business rules, regulatory guidelines, policies and procedures to determine clinical appropriateness for acute care authorizations.
• Support strategies to comply with state, federal, CARF, NCQA, and HEDIS regulations/initiatives.
• Provide support to community partners and network staff related to acute services and best practices.
• Determines clinical appropriateness for Specialist Reviews and Specialist Approvals.
• Conducts concurrent clinical case reviews as requested and provides recommendations for follow up.
• Conducts retrospective reviews of service provision to ensure services were provided in the appropriate amount, scope, and duration to reasonably achieve goals as outlined in the Individualized Plan of Service.
• Utilizes knowledge of protocols and audit tools to conduct clinical audits and ensures inter-rater reliability within timeframes outlined.
• Conducts retrospective reviews for acute care admissions utilizing the MCG Parity Tool and completes comprehensive reviews of acute care admissions.
• Reviews and contributes to the development and continuous updating of protocols, audit tools, procedures, and processes within the Utilization Management department.
• Additional duties as assigned.

Job Requirements and Qualifications

Education :

• Master's degree in relevant discipline required.

Training Requirements (licenses, programs, or certificates):

• State of Michigan license, certification and / or registration as, Psychologist (LLP, LP), Social Worker (LMSW), Counselor (LPC), Marriage and Family Therapist (LMFT) or Nurse (RN).
• For children’s services - maintain/attain 24 hours annually of child-specific training (Child Diagnostic and Treatment Professional).

Experience Requirements:

• Minimum of two years’ experience working in the human health and service field.

Preferred Experience:

• Experience in working with electronic health records
• Prior experience working in a crisis or psychiatric hospital service environment (hospital, crisis center, community mental health agency, ACT team)
• Experience with data entry
• Experience working with adults with severe mental illness, substance use disorder or intellectual/developmental disabilities
• Experience working with children with serious emotional disturbance

Job Specific Competencies/Skills:

• Demonstrates effective interpersonal skills.
• Demonstrates ability to work effectively in a team environment.
• Demonstrates effective negotiation skills.
• Demonstrates effective written and oral communication skills.
• Demonstrates effective computer skills.
• Demonstrates effective project management/organizational skills.
• Demonstrates effective de-escalation and problem-solving skills

Knowledge Requirements:

• Knowledge of medically necessary criteria for acute care behavioral health treatment
• Knowledge of the Michigan Mental Health Code, HIPPA, Medicaid Provider Manual
• Knowledge of the clinical care process-crisis continuum (screening, crisis assessment, treatment planning, case management and continuing care)
• Knowledge of the practices and principles of psychological, emotional, and social assessment and diagnosis

Oakland Community Health Network’s Core Competencies:

• Interacting with others in a way that gives them confidence in one’s intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity/Building Trust)
• Making individuals and their needs a primary focus of one’s actions; developing and sustaining productive relationships, recognizing that the individual is the person served. (Individual Focus)
• Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning)
• Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards)
• Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)

Additional Information

( Travel required, physical requirements, etc.):

• Must have available means of transportation to and from OCHN.
• All shifts are virtual
• Must be available for meetings and events which may occur outside of standard office hours.
• The ideal candidate must be able to complete all physical requirements of the job with or without reasonable accommodation.

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees’ differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.